Twenty-Five Years of Alcohol Epidemiology: Trends, Techniques, and Transitions.

Alcohol epidemiology has developed as a discipline only in the second half of this century. The recognition of alcoholism as a diagnosable disease has permitted extensive studies of trends in alcohol consumption and its consequences throughout the United States.


A HISTORICAL PERSPECTIVE
identifiable etiological agent (e.g., a bacteri disease, injury, or other health um or virus); a clearcut case identification; related condition in human popu Epidemiology has its roots in the study of a short clinical course; and a quickly effec lations and of those factors that infectious diseases. Such research first tive prevention (vaccination) or treatment increase the likelihood that such a condi used the public health model, which (antibiotics). The epidemiology of chronic tion will occur (Lilienfeld and Lilienfeld involves defining a disease agent, host, diseases such as cancer and heart disease 1980). Thus, the primary aim of alcohol and environment, to study and control is more complex. Alcohol epidemiology, epidemiology is to identify and explain epidemics. During the early and mid20th however, is even more intricate and chal the factors that shape the distribution of century, medical advances and improve lenging because of the multiplicity of its alcohol use, abuse, and dependence and ments in sanitation led to the mastery of contributing factors. It encompasses alco the consequences in various populations. many infectious diseases, such as tubercu hol use, abuse, and dependence as well Such a goal necessarily involves first losis. Soon thereafter, cancer and heart as countless medical, psychological, defining the distribution of alcohol con disease gained recognition as common social, legal, and economic consequences. sumption and its related problems in the killers. This resulted in establishing a new Difficulties also arise in determining the population. Describing the nature and discipline-chronic disease epidemiolo incidence of alcohol dependence. To magnitude of alcohol's impact on the gy. In addition, the field of epidemiolo accurately count something, such as the individual and on society are necessary gy's focus shifted to assessing the general number of alcoholdependent people in the for developing effective prevention, health of communities under normal United States, one must first be able to intervention, and treatment strategies.
conditions rather than only under specific define it. The large number of definitions This article examines trends in alcohol epidemic circumstances. in alcohol research adds to the complexity consumption and in related factors, such Alcohol epidemiology as a unique of its epidemiology. And, although no one as cirrhosis mortality, in the United States discipline is a relative newcomer to the during the past 25 years. It also traces the field, and it marks a logical progression in evolution and maturation of the science the evolution of the science of epidemiolo MARY C. DUFOUR, M.D., M.P.H., is deputy of alcohol epidemiology over the corre gy. The epidemiology of many infectious director of the Division of Biometry and sponding timeframe and speculates on diseases is relatively straightforward, Epidemiology of NIAAA, Bethesda, future directions in the field.
having a specific, welldefined, easily Maryland.
would argue about whether cancer or heart disease fits the medical model of a dis ease, some people still would insist that alcohol dependence does not fit this cate gory. Because of the frequent fluctuations in these definitions and concepts, alcohol epidemiology is a new and rapidly evolv ing discipline.

SURVEILLANCE EPIDEMIOLOGY
Alcohol epidemiology's complexity is best tackled by dividing the field into disciplines with different foci (see below and sidebar, p. 81). One of the hallmarks of epidemiology is surveillance-that is, tracking a disease, injury, or other health related condition over time to ensure early detection of epidemics and to measure the impact of prevention and intervention efforts. Important factors tracked in alco hol epidemiological surveillance include apparent per capita alcohol consumption, cirrhosis mortality, alcoholrelated traffic deaths, alcoholrelated morbidity among patients discharged from shortstay com munity hospitals (i.e., those, excluding military or Veterans Affairs hospitals, wherein patients remain for less than 30 days), and use of alcoholism treatment services (the limitations of these ap proaches are discussed below).

Apparent Per Capita Alcohol
Consumption. This measure provides a global gauge of societal alcohol consump tion and is calculated by dividing the alcoholic beverage sales data from every State and the District of Columbia (or shipment data from major beverage indus try sources in cases in which States did not provide sales data) by the U.S. population age 14 and older 1 (Williams et al. 1994). After Prohibition in the United States, per capita alcohol consumption increased throughout the 1960's and 1970's, peak ing in 1980 and 1981 at just below 2.8 gallons of pure alcohol per year. During the remainder of the 1980's, per capita consumption showed a 12percent de crease, the only sustained decrease since Prohibition (figure 1; Williams et al. 1994). In 1991 per capita consumption experienced one of its largest annual decreases ever, dropping to 2.31 gallons from 2.46 in 1990. In 1992 it remained level at 2.31 gallons, the lowest amount since 1965 (Williams et al. 1994).

Cirrhosis Mortality.
Among alcohol related chronic medical conditions, alcoholic liver disease (i.e., alcoholic cirrhosis) is the leading cause of death. Data regarding deaths from cirrhosis (which includes but is not limited to alcoholic cirrhosis) are compiled using national death records collected annually by the National Center for Health Sta tistics (NCHS). In 1991, 25,562 people in the United States died from cirrhosis (Savage et al. 1994), making it the 11th leading cause of death (NCHS 1994

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heavy drinkers apparently played a major role in alcoholrelated crashes. During 1992 the proportion of traffic deaths that were alcohol related reached a 14year low of 37.4 percent (Zobeck et al. 1994). The number of male drivers involved in alcoholrelated fatal crashes decreased 30 percent between 1979 and 1992, whereas the corresponding number of female drivers increased 4 percent over this period (Zobeck et al. 1994).

AlcoholRelated Morbidity Among Patients Discharged From ShortStay
Community Hospitals. Alcoholrelated hospital discharge data are tracked with data obtained from the National Hospital Discharge Survey series, a national sample of hospital discharge episodes, conducted on an ongoing basis since 1965 by NCHS. Current surveillance of alcoholrelated discharges began in 1979, the year in which the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) was imple mented for coding hospital records in the United States. In 1992 (the most recent year for which data are available) there were a total of approximately 28,420,000 discharges for persons age 15 and older from shortstay hospitals, with approxi mately 423,000 (1.5 percent) of these discharges having an alcoholrelated diag nosis that was listed first in the records and approximately 1,175,000 (4.1 percent) having an alcoholrelated diagnosis listed anywhere in the records (for each discharge episode, up to 7 diagnoses may be listed). Alcoholdependence syndrome composed the majority (64 percent) of firstlisted diagnoses, followed in order by cirrhosis (17 percent), alcoholic psychoses (12 percent), and nondependent alcohol abuse.
The order of these firstlisted alcohol related diagnoses has remained relatively constant over the 14 years from 1979 through 1992. Overall, hospital discharges with alcoholrelated diagnoses demon strated little significant change over this period (Caces et al. 1994).

Use of Alcoholism Treatment Services.
The past 25 years have witnessed dramatic increases in the number of people using alcoholism treatment services. Statistics from the National Drug and Alcohol Treatment Utilization Survey reveal that over the interval from 1979 to 1991, the number of people in treatment on a given day during the year almost doubled from approximately 293,000 people in treatment on April 30, 1979 (National Institute on Alcohol Abuse and Alcoholism [NIAAA] 1980), to approximately 575,000 on September 30, 1991 (National Institute on Drug Abuse 1992). Membership in Alcoholics Anonymous increased in an equally dramatic manner, rising from approximately 445,000 members in 1979 to nearly 980,000 in 1989 (General Services Board of Alcoholics Anonymous 1991).

Beyond Surveillance
Data used for surveillance must be easy to quantify, costeffective to obtain, and available on a periodic (preferably annual) basis. Factors mentioned above, such as cirrhosis, meet these criteria and, in doing so, provide much useful information on alcohol use and alcoholrelated conse quences. Indeed, rates of all cirrhosis Rate per 100,000 Population Rate per 100,000 Population 1910 1920 1930 1940 1950 1960 1970 1980 1990 1970 1974 1978 1982 1986 1990 Revisions

Figure 3
Rate per 100 Million VMT 1979 1981 1983 1985 1987 1989 1991 ■ • ■ All fatalities Alcohol-related fatalities • Total and alcohol-related traffic fatality rates per 100 million vehicle miles traveled (VMT) in the United States during 1979 to 1992. SOURCE: Zobeck et al. 1994. mortality have correlated very well with levels of alcohol consumption in many time periods and many nations. In the United States, death rates from cirrhosis decreased nearly 50 percent within 4 years of Prohibition enactment in 1916, remained low during Prohibition, and began to increase steadily after its repeal in 1932 (Dufour et al. 1993).

Limitations of Surveillance Data.
Surveillance measures, including estimat ed per capita alcohol consumption, are quite crude. For example, not all alcoholic beverages produced are actually con sumed, and illicit alcohol production, home production, and taxfree personal imports usually are not counted. Most importantly, although per capita con sumption fairly accurately reflects the total alcohol volume consumed in a par ticular geographical area, it provides no information about how consumption is distributed among people in that area; instead, these data assume that all people consume equal amounts.
In reality, not all people drink alcohol, and in fact, the small segment of the population that drinks most heavily has the greatest impact on the total volume of consumption. One person who consumes 10 drinks per day will contribute as much to the total volume as 70 people who consume a single drink each once per week. Clearly, different types of epidemi ological studies must be conducted to examine these individual differences.
Likewise, when examining cirrhosis mortality data, alcohol researchers seek to ascertain the number of cirrhosis deaths attributable to alcohol. Because not all cirrhosis is alcohol related, considering all cirrhosis statistics as representative of alcoholic cirrhosis overestimates alcohol's impact. However, presenting only cirrhosis statistics specifically identified as alcohol related seriously underestimates the true magnitude of the problem. The "alcohol relatedness" of most conditions is grossly underestimated on death certificates for a variety of reasons, including the certifying physician's lack of familiarity with the decedent's drinking history and the physi cian's desire to protect survivors from the stigma of being identified as the family of an alcoholic (Dufour et al. 1993). The actual number of alcoholic cirrhosis deaths lies somewhere between these two meas ures, and other data sets, combined with national death records, are required to arrive at this number.

A MULTIPLICITY OF RESEARCH TRADITIONS
When discussing trends in national drink ing patterns and problems over the past 25 years, it is useful to examine the contexts, volumes, and patterns of drinking that lead to specific alcoholrelated problems. Seeking these kinds of information leads from surveillance epidemiology, which defines the prevalence of alcohol con sumption and related problems in the population, to survey research. When preparing to conduct a study of drinking contexts and factors, researchers' concep tualizations of alcoholrelated problems will determine how drinkingrelated questions on surveys are framed and what actual data will be obtained.

PopulationBased Survey Research
A critical advantage of survey data over consumption statistics (such as those in figure 1) is that each respondent's drinking patterns are recorded separately and can be correlated with other personal characteris tics. Modern alcohol epidemiology is a conglomeration of distinct epidemiological disciplines, each of which attempts to describe the problem of alcoholism in the United States from a different etiological perspective (see sidebar, p. 81). Thus, surveys differ with respect to their goals and findings depending on which epidemi ological perspectives they are based.

Looking Back at Survey Research.
Rigorous modern survey research methodology first was applied to an in depth study of drinking practices in a survey of college students conducted in 1949 (Straus and Bacon 1953). This study was remarkable at the time because it included questions about frequency of drinking, quantities typically consumed per occasion, and even the occurrence of some types of problems resulting from drinking. Beginning in the 1960's with the work of Cahalan and colleagues (1969), nationwide surveys of drinking practices have applied full statistical sampling methods, which allow the re sults to be projected with a known degree of confidence to the entire adult house hold population of the country. Since then, periodic surveys conducted by the NIAAAsponsored alcohol research cen ter in Berkeley, CA, not only have made it possible to keep up to date on American drinking practices but also to examine changes in these practices over time.
The results of these studies indicate either stability in drinking levels or a slight increase in the prevalence of heavier drink ing among men over the period from 1964 to 1984 (Clark and Hilton 1991). Looking at more recent trends, Williams and DeBakey (1992) examined changes in alcohol consumption in the United States from 1983 to 1988 using the 1983 and 1988 National Health Interview Surveys (NHIS; conducted by the NCHS) and found an

EPIDEMIOLOGY: FOUR RESEARCH PERSPECTIVES
Alcohol epidemiology has developed as a conglomeration of four major epidemiological perspectives: psy chosocial epidemiology, psychiatric epidemiology, chronic disease epi demiology, and epidemiological soci ology. Research conducted using each perspective seeks slightly different information from study participants. In this manner, the four disciplines com plement each other in revealing drink ing patterns and problems among the U.S. population.

Psychosocial Epidemiology
Historically, psychosocial epidemi ology and psychiatric epidemiology (discussed below) share common roots. Prior to World War II, both disciplines relied on key community and medical informants (i.e., profes sionals in a position to know the num bers of people hospitalized with or suffering from a condition of interest) and agency records for information that defined alcoholrelated trends in the population. Following World War II, a second generation of studies evolved that used objectively scored measures of psychopathology, psychiatrists' evaluations of profiles compiled from written interview responses, and re sponses of community respondents personally interviewed by psychia trists. The psychosocial epidemiology perspective espouses the concept that distinct psychiatric disorders, includ ing alcoholuse disorders, are merely different manifestations of common etiological factors, particularly social stress. Consistent with this concept of social causation was the unitary con cept of mental illness, in which psy chiatric disorder was postulated to fall along a continuum as opposed to being seen as a collection of distinct disor ders. This perception clearly differs from the simple causeandeffect sys tem used in traditional medicine. In keeping with the dimensional approach to the measurement of psychopathology, psychosocial epidemiologists rely on the psychometric tradition of psychology, wherein researchers depend on selfreports from subjects who answer closed ques tions by selecting from answers given in a multiplechoice format (Grant in press).

Psychiatric Epidemiology
In contrast with psychosocial epidemiolo gy, psychiatric epidemiology measures mental disorders, including alcohol use disorders, primarily by categorizing them. By providing a category for alcoholuse disorders, this perspective accepts alco holism as a medical disease entity. The psychiatric epidemiology perspective is based on the clinical examination tradi tion (i.e., interviews with patients) typical in psychiatry. Most early semistructured clinical interviews either entirely exclud ed or poorly represented alcoholuse disorders. By comparison, more recent interviews incorporate questions about alcoholuse disorders. 1 As psychiatric epidemiology has evolved, two series of interview instru ments have emerged-one designed to be administered by clinicians and the other developed for use by lay interview ers. The latter series consists of fully structured clinical interviews that yield computergenerated diagnoses of alcohol use disorders (Grant in press).

Chronic Disease Epidemiology
Traditionally, this perspective has focused on such medical maladies as heart disease 1 Changes over the past 25 years in the definitions of many psychiatric disorders have resulted in the continual need to develop new instruments to assess evolving criteria. For example, criteria for alcohol use disorders appearing in the third edition of the and cancer. Data on various chronic illnesses, as opposed to mental dis orders, have been gathered since the turn of the century. However, informa tion on alcohol use, symptoms, and consequences was not collected rou tinely until the early 1970's, because alcohol dependence was not viewed as a chronic disease. By sponsoring regular surveys, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) has played an important role in establishing alcohol dependence in this category.

Epidemiological Sociology
This perspective represents the synthe sis of several epidemiological ap proaches to the study of alcohol use and abuse and their consequences. Here, use and consequences are stud ied independently rather than being treated as one psychiatric condition. The 1960's marked the beginning of systematic epidemiological sociologi cal surveys of the general population throughout the United States. Most of these national and community studies were sponsored by NIAAA and its pre decessor within the National Institute of Mental Health. Researchers at the Alcohol Research Group in Berkeley, CA, have conducted, at approximately 5year intervals, eight national surveys as well as numerous community stud ies since the first one was completed in 1965. These researchers have in vested much effort in maintaining some degree of comparability across surveys despite changing definitions and conceptualizations of alcoholuse disorders (Grant in press). increase in abstention and a decrease in heavier drinking. The large number of respondents in both of these surveys (the 1983 NHIS included 22,418 respondents and the 1988 NHIS included 43,809 respondents) made it possible to explore trends separately by gender as well as other sociodemographic characteristics often associated with variations in alcohol consumption. For women, decreases in heavier drinking were found among those 18 to 44 years old, those employed, and those divorced or separated or never married. For men, decreases were found among those em ployed, those with a family income of $25,000 or more, and those married or divorced or separated (each of these factors contributed significantly to de creasing heavier drinking on its own).

NIAAA's Role.
Traditionally, questions about alcohol in study surveys have con sisted of a limited number of items on drinking practices, problems, and reasons for drinking. However, as NIAAA has played an increasingly active role in designing and sponsoring these surveys, the detail and complexity of the alcohol related data have improved dramatically, progressing from minimal quantity and frequency questions in the late 1970's to 120 questions on the Alcohol Supplement of the 1988 NHIS (Grant in press). The 1988 NHIS is especially noteworthy because it represents a step in the matura tion of alcohol epidemiology, signaling the recognition of alcoholism as a diag nosable disease (see sidebar, p. 81). The NHIS is a mainstream national health survey instrument from which actual diagnoses of alcohol abuse and depend ence based on criteria listed in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) could be made in a large national general household population.
NIAAA has played a critical role in numerous other NCHSdirected national surveys. The 1983 Hispanic Health and Nutrition Examination Survey marked the first national survey of subpopulations of HispanicAmericans in the United States that included alcohol consumption and health consequences. The NIAAAsupported Alcohol Epidemiologic Data System (AEDS; see box, this page) had major responsibility for refining and analyzing the alcoholrelated data from this survey. NIAAA also participated in the Epidemio logic Followup Study of the National Health and Nutrition Examination Survey (NHANES-a nationwide survey of medi cally defined illness ascertained through physical examination), a longterm longitu dinal followup of participants in the 1971-74 NHANES I. These individuals were followed up in 1982-84, 1986, 1987, and 1992-93, allowing epidemiologists to examine morbidity and mortality as they related to alcohol consumption over the participants' lifespans. NIAAA's participa tion in the 1986 National Mortality Follow back Survey, which examined a 1percent sample of all deaths occurring in the United States in 1986 (using death records, hospital records, and nextofkin inter views on lifetime alcohol consumption and many other healthrelated questions), has enabled a detailed examination of the alcoholrelatedness of cirrhosis deaths.

National Longitudinal Alcohol Epidemiologic Survey
The most recent national information on drinking patterns and problems is derived from the 1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES). NLAES is a nationwide household survey with 42,862 respondents designed and sponsored by NIAAA and fielded by the Bureau of the Census. This study is a landmark in alcohol epidemiology for several reasons. The NLAES is the largest survey ever to focus primarily on alcohol and other drug use and abuse disorders and the first of its magnitude to be con ducted by NIAAA. In addition to measur ing patterns of use, NLAES is designed to assess the presence of symptoms of past year alcohol abuse and dependence across several diagnostic classification schemes-including DSM-III, DSM-III-R, DSM-IV, and ICD-10-through the use of the diagnostic instrument called the Alcohol Use Disorders and Associated Disabilities Interview Schedule (AU DADIS). Dr. Bridget Grant of NIAAA and Dr. Deborah Hasin, an NIAAA funded researcher ), designed the AUDADIS especially for NLAES. 3

ALCOHOL HEALTH & RESEARCH WORLD 82 THE ALCOHOL EPIDEMIOLOGIC DATA SYSTEM
In 1988 it was estimated that 15.3 million people in the United States over age 18 abused and/or were dependent on alcohol. How many were women? How many attended alcoholism treatment services? Answers to these and other questions about alcohol are available to both the government and the public through the National Institute on Alcohol Abuse and Alcoholism's (NIAAA's) Alcohol Epidemiologic Data System (AEDS).
Established in 1977 to acquire and analyze epidemiological data on alcoholrelated subjects for use by NIAAA, AEDS has developed an extensive repository of statistics on problem drinking, consumption patterns, mortality, morbidity, and other relevant issues. AEDS operates under the auspices of NIAAA's Division of Biometry and Epidemiology and assists NIAAA's alcoholism surveillance effort by providing researchers with current drinkingrelated data as well as census and vital statistics information.
In addition to publishing research reports based on its analyses, AEDS manages the Quick Facts electronic bulletin board, which enables anyone with a computer and modem to access uptodate facts on alcoholrelated topics, such as abuse and depend ency statistics and information on the costs (i.e., marketing expenses) of alcohol.
Quick Facts uses a bulletin board system (BBS) software package and does not require an online fee, although outofarea users must pay longdistance telephone charges. Quick Facts is available using the following specifications: Quick Facts also is available on the Internet through telnet fedworld.gov (192.239.93.3) or www fedworld.gov for worldwide web users. From FEDWORLD, proceed to HEALTH MALL, then to Health Gateway Systems, and select #118 for Quick Facts.
-Kathryn G. Ingle Additional data items on the NLAES include family history of alcohol use disor ders; physical health and medical conse quences of alcohol use; and use of health care services, including alcoholism and other drug abuse treatment services. Pre liminary analyses of the 1992 NLAES revealed that 44 percent of American adults (56 percent of men and 34 percent of wom en) age 18 and older were current drinkers who had consumed at least 12 drinks in the year preceding the interviews. Twentytwo percent were former drinkers, and 34 per cent were lifetime abstainers (22 percent of men and 45 percent of women abstained). These figures reflect an 8percent decrease in the prevalence of current drinking rela tive to 1988 (Dawson et al. in press). The proportion of current drinkers (i.e., the full spectrum of drinkers as distinguished from heavier drinkers discussed earlier) de creased with age, increased with income and education, was lower in the South than in other regions, and was lower in rural than in urban areas.
The 1year prevalence of combined alcohol abuse and dependence in the United States for 1992, as assessed using DSM-IV criteria in the NLAES sample, was 7.41 percent, representing 13,760,000 Americans. In addition, the 1year preva lence of combined alcohol abuse and 3 The DSM-IV and ICD-10 were not finalized at the time this survey was fielded. However, because of their critical roles on the committees formulating the ICD-10 and DSM-IV, Drs. Grant and Hasin were able to incorporate all of the specific diagnostic criteria necessary to make diagnoses of alcohol related disorders under both classification schemes  dependence was much greater for men (11.0 percent) than for women (4.08 percent). Furthermore, prevalence de clined with increasing age. The highest rates for both men (22.07 percent) and women (9.84 percent) were noted among those composing the youngest age group (ages 18 to 29) ). The overall prevalence and corresponding population estimates of alcohol abuse and dependence for 1992 are not substantially different from those for 1984 (Williams et al. 1989) or for 1988 (Grant et al. 1991;1984 figures are based on DSM-III diag nostic criteria and those for 1988 are based on DSM-III-R diagnostic criteria).
The NLAES represents a major inte gration of epidemiological research tradi tions as well as maturation of the field of alcohol epidemiology. Additional ongoing projects in epidemiology sponsored by NIAAA include a cooperative study with the National Heart, Lung, and Blood Institute of the interactions of alcohol consumption with borderline hypertension (for further information and other pro jects, see table 1).

FUTURE TRENDS IN EPIDEMIOLOGY AT NIAAA
Because of NIAAA's move to the National Institutes of Health in October 1992, NIAAA now stands as a full and respected partner in the scientific research community. Alcohol researchers are making exciting progress. With a new century and a new millennium just a few short years away, what direction will alcohol epidemiology take in the second 25 years of NIAAA history?
It is unlikely that NIAAA will conduct additional large national surveys on its own in the near future. There are, however, many areas that further studies should address: • Longitudinal studies, which follow participants at intervals over a period of years or decades, should be con ducted to alter the focus of epidemio logical research from "snapshots" of drinking problems at a single point in time to descriptions of drinking pat terns and consequences over a per son's natural life course. These studies must be carefully designed to be nar rowly focused and costeffective.
• New strategies should be developed for surveying special populations in the United States (including AsianAmericans, American Indians, and Alaska Natives) for whom infor mation on alcoholrelated factors is lacking.
• Innovative survey methods should be developed that make use of discover ies in basic science. For example, collecting blood samples from survey respondents may prove useful when laboratory tests for biological markers of alcoholism have been developed. Participants' responses to survey questions could then be correlated with the presence or absence of bio logical markers in their blood.
• Advances in computer hardware and software in areas such as mathematical modeling should be explored for their applicability to alcohol epidemiological research.
• More creative and prudent use should be made of existing epidemiological data. For example, metaanalyses of multiple studies can increase scien tists' understanding of relationships between many alcoholrelated vari ables (Fillmore et al. 1991).
Finally, epidemiologists must develop better methods for estimating globally the alcoholrelated problems in a commu nity, region, or nation. Although commu nity surveys, such as those cited in this article, are valuable data sources, they generally are limited to households. This means that people not in households at the time of the survey-those who are homeless; incarcerated by the criminal justice system; or residing in rooming houses, hospitals, nursing homes, or mental health facilities-do not partici pate. These groups are likely to have a much higherthanaverage prevalence of heavy alcohol use and alcoholrelated problems. Therefore, a methodology to estimate the complete scope of alcohol use and problems would be an important contribution to alcohol epidemiology. Weisner and Schmidt (1994) have pioneered such a global approach using data collected under the auspices of the Alcohol Research Group's Community Epidemiology Laboratory. The laboratory includes a variety of data collected from a single county in northern California and uses an assortment of methodological approaches to estimate total alcohol prob lems in the community. Such techniques would be extremely valuable in describ ing the total range of alcohol problems in the United States.
By incorporating these suggestions for more effective and efficient epidemiologi cal studies, NIAAA intends to continue a strong tradition of research in this field throughout its second 25 years. ■